Is APA Ruining Clinical Training?

Extensive requirements leave little time to reflect.

Posted Jan 31, 2017

It is a truism of power theory that in every system, rules are made initially for the good of the system; eventually, however, the rulemakers become a hegemony of powerful interests, and rules are made for the good of the hegemony. In psychology, this is a problem in therapy, where techniques are designed originally for the good of the client but morph into conveniences for the therapist. It’s also a problem in clinical training, where the rules governing accreditation by the American Psychological Association were originally designed to identify clinical psychology programs but have come to impose so many requirements on them that a horde of psychologists at APA are needed just to monitor and accredit programs.

A doctoral degree in psychology in the USA need not come from an APA-accredited program, but unaccredited programs have trouble competing for good students, who then have trouble getting good (APA-accredited) internships. Many states automatically accept APA-accredited degrees for licensing purposes. APA-accreditation is not hard to get, judging by the success rate of programs seeking it. However, to get it, a program must undergo a time-consuming self-study and a site visit, and it must conform to a long list of content requirements. For example, we have to offer a course on Cognitive and Affective Models and a course on Ethics. Mission creep produces an ever-increasing list of required courses.

I came across my graduate transcript recently, and I compared it with the transcripts of the students whom I teach these days. I started graduate school in 1974 in a program with 15-week trimesters; I teach in a 10-week quarter system, so I will translate my trimester hours into our quarter system for the comparison. For semesters, divide credit hours reported below by 3 and multiply that by 2.

Our students take 135 hours of coursework (up to 45 of which can be waived if they enter with a master’s degree). Required courses account for 101 quarter hours, leaving 34 for electives. A large portion of these required courses are required because of APA standards for accreditation, although we require 3 theory courses, 4 (rather than 1) multicultural courses, and 12 courses on therapy practice because we think they’re important. My program required 105 (quarter) hours in all, but 28 of these, at least in my case, were “dissertation” or “practicum” hours, meaning you paid the tuition but didn’t have to do anything extra to get the credits. I had about half as many required courses as my students now have (49 quarter hours), and took 28 hours of electives, including Art of Japan and Modern Sculpture. I took 2 statistics courses as our students do, but all the other courses I took were directly relevant to clinical work. Our students take courses in program development, research methods, qualitative research, consultation, supervision, the history of psychology, physiology, neuropsychology, issues in measurement, ethics, diagnosis, and so on.

Who received the better education? Our students certainly take a lot more classes than I did in a lot more subjects. I learned research methods in the old mentorship model, working on a dissertation with researchers. I learned issues in measurement trying to figure out what to make of scores on tests. My classmates and I would get together for coffee and talk about the articles we were reading. Eight of us felt we needed to learn group dynamics and how to make interpretations in the right spirit, so we met weekly and practiced on each other. My students read or skimmed hundreds of pages a week to keep up with their classes. I would go home at the end of the day in grad school and read literature.

Once I conducted a survey asking psychologists what truly important things they had read. The results were varied (and provided me a reading list). Then I asked if these had been assigned for a class. Almost no one had named a book or article that had been assigned for a class. I read Kernberg not for a class but to make sense of a seriously disturbed patient I was struggling with. Ditto Horney, Minuchin, and Selvini. So sure, I teach Bayes’ Theorem in our clinical program, but do my students learn it nearly as well as I did when a professor said it was crucial to good assessment and I had enough free time to figure it out?

Who can complain about requiring a course on ethics? Well, I can. Why can’t students just be handed the ethical rules, as we were, and told not to violate them? Is there any evidence that taking a course on the subject reduces the number of violations? I doubt it. Instead, once it becomes a course, the instructor has to fill up the time with more readings, more discussions, and so on. What ought to take an hour or two becomes a 60-hour slog.

My graduate education worked only because we were active learners, people who were motivated to find out what they needed to know to practice effectively. Perhaps we were like that when we started the program. But more likely, the program cultivated our active learning by providing us with large swaths of free time and lots of clients for us to think about. I worry that the program I teach in, like all contemporary clinical programs, cultivates passivity (not in all the trainees by any means, but in many). The result is a profession waiting for the real experts to tell them what the textbooks say, what studies say, and what will work, usually in the form of simple, specialized assessment instruments and treatment manuals. After all, the training program itself is told by the real experts at APA what to teach.